Service AgreementsService Agreements

Mike Davies, MDMark Murray and Associates

Mike Davies, MDMark Murray and Associates

Other IndustriesOther Industries

•“Live and die” on the product

•Define the timelines and handoffs

•Define expectations of each party

•Constantly measure conformity to expectations

•Refine and improve handoffs

•“Live and die” on the product

•Define the timelines and handoffs

•Define expectations of each party

•Constantly measure conformity to expectations

•Refine and improve handoffs

Big System FlowBig System Flow

TestTest

SCSC SurgerySurgery

External DemandExternal Demand

PCPC

TestTest

“We Are All Related”“We Are All Related”

Definition of a Service Agreement:Definition of a Service Agreement:

Understanding or agreement between any 2 parties, one of which sends work

to another, defining work flow rules.

Understanding or agreement between any 2 parties, one of which sends work

to another, defining work flow rules.

AgreementAgreement

•Sender – sends the right work packaged the right way

•Receiver – is accessible for performing the right work right away

•Sender – sends the right work packaged the right way

•Receiver – is accessible for performing the right work right away

Why are Service Agreements Important?

Why are Service Agreements Important?

•Define relationships between primary and specialty care

•Reduce demand for specialists

• Improve referral process

•Decrease delay in care

•Define relationships between primary and specialty care

•Reduce demand for specialists

• Improve referral process

•Decrease delay in care

Who are the stakeholders in the referral relationship?

Who are the stakeholders in the referral relationship?

PatientsPatients

•Reassurance

•Expectation for the process

•Knowledge of the process

•Certainty

•Speed

•Quality of the care and the experience

•Appropriate referral

•Reassurance

•Expectation for the process

•Knowledge of the process

•Certainty

•Speed

•Quality of the care and the experience

•Appropriate referral

Primary CarePrimary Care

•Access to SC

•Speed

•Know SC expectations

•Simple process

•Certainty of appointment

•Questions answered

•Let my people go

•Access to SC

•Speed

•Know SC expectations

•Simple process

•Certainty of appointment

•Questions answered

•Let my people go

Specialty CareSpecialty Care

•Knowledge of which doctor is referring

•Right patients sent with right information

•Patient expectations

•PC expectations

• (When do I) let the people go?

•Knowledge of which doctor is referring

•Right patients sent with right information

•Patient expectations

•PC expectations

• (When do I) let the people go?

Common InterestsCommon Interests

•PC and PatientsSpeed

Certainty of appointment

Answers

•SC and PCExpectations of each other

•PC and PatientsSpeed

Certainty of appointment

Answers

•SC and PCExpectations of each other

Four Components to Service Agreement

Four Components to Service Agreement

1.Define and discuss the work – Who? What? How much?

2.Sender – sends right work packaged the right way

3.Receiver – does right work right “right away”

4.Referee – monitors agreement

1.Define and discuss the work – Who? What? How much?

2.Sender – sends right work packaged the right way

3.Receiver – does right work right “right away”

4.Referee – monitors agreement

1. Define and Discuss the Work

1. Define and Discuss the Work

What is the work?

Who is sending it?

How much work exists?

What is the work?

Who is sending it?

How much work exists?

Sample of Consult Rate Q2 ‘02Sample of Consult Rate Q2 ‘02

Consults 2ndQuarter 02Provider

Consults 2ndQuarter 02Provider

Neu

rolo

gyN

euro

logy

Ort

hope

dics

Ort

hope

dics

Psyc

hiat

ryPs

ychi

atry

Uro

logy

Uro

logy

Car

diol

ogy

Car

diol

ogy

Der

mat

olog

yD

erm

atol

ogy

ENT

ENT

Neu

rolo

gyN

euro

logy

11 00 1212 1818 99 11 11 22 0022 00 00 22 11 00 00 00 0033 00 11 00 00 00 00 00 0044 00 22 11 11 00 00 00 0055 66 1111 1414 77 22 00 44 6666 00 00 00 00 00 00 00 0077 11 22 1515 66 00 66 22 1188 22 66 44 1010 00 00 22 2299 00 11 00 00 00 00 00 00

1010 1212 88 1515 66 11 66 33 12121111 44 88 77 99 22 44 44 441212 33 44 3030 77 11 66 22 331313 00 11 22 00 00 22 00 001414 55 1515 1111 1010 11 55 33 551515 44 22 1717 99 00 1313 33 44

Reasons for Referral to Urology Q2 '02Reasons for Referral to Urology Q2 '02

00

1010

2020

3030

4040

5050

6060

7070

BPHBPH UTIUTI M. HemM. Hem S. MassS. Mass InconIncon B TumorB Tumor R TumorR Tumor

Urology Referral by Provider Q2 '02

Urology Referral by Provider Q2 '02

00

55

1010

1515

202011 33 55 77 99 1111 1313 1515 1717 1919 2121 2323 2525 2727 2929 3131

ProviderProvider

Num

ber o

f Ref

erra

lsN

umbe

r of R

efer

rals

Areas to Target for SAAreas to Target for SA

•High volume diagnosis•High volume diagnosis

Areas to Target for Focused EducationAreas to Target for Focused Education

•High volume referring providers

Face-to-Face Communication Needed at This Point!Face-to-Face Communication Needed at This Point!

•Organize all service members or key representatives to a meeting – facilitated if necessary

•Present the data

•Discuss the data, practices, history, problems, potential solutions and recommendations

•Organize all service members or key representatives to a meeting – facilitated if necessary

•Present the data

•Discuss the data, practices, history, problems, potential solutions and recommendations

Halt!Halt!

Draft Improvement IdeasDraft Improvement Ideas

•Draft list of appropriate reasons for referral

•Draft list of work up needed before the specialty appointment

•Circulate the proposal to everyone affected and consider all comments

•Draft list of appropriate reasons for referral

•Draft list of work up needed before the specialty appointment

•Circulate the proposal to everyone affected and consider all comments

2. Sender Sends Right Work (Packaged) the Right Way

2. Sender Sends Right Work (Packaged) the Right Way

What is the right work?System-wide BPH Referral Guidelines – Refer When:

What is the right work?System-wide BPH Referral Guidelines – Refer When:

1. Medical failure – symptoms not controlled, residual urine not reduced.

2. Adverse reaction to recommended medication

3. Possible obstructive uropathy – elevated BUN/Creat – not improved with medication

4. Patient desire for definitive surgical treatment.

1. Medical failure – symptoms not controlled, residual urine not reduced.

2. Adverse reaction to recommended medication

3. Possible obstructive uropathy – elevated BUN/Creat – not improved with medication

4. Patient desire for definitive surgical treatment.

a. Physician Factorsb. Referral Processc. Patient Experience

a. Physician Factorsb. Referral Processc. Patient Experience

2. Sender Sends Right Work (Packaged) the Right Way

2. Sender Sends Right Work (Packaged) the Right Way

Physician FactorsPhysician Factors

Packaging the referralPackaging the referral

Physician Factors: Package Right Way

Physician Factors: Package Right Way

•Refer the “right” problem

•“Sell” the consult to the patient (closing the visit)

•Clarify expectations

•Provide the right information to the specialist

•Refer the “right” problem

•“Sell” the consult to the patient (closing the visit)

•Clarify expectations

•Provide the right information to the specialist

Microscopic Hematuria – Refer With:Microscopic Hematuria – Refer With:

1.Verify presence of three UA’s with at least six RCBs/HPF

2.Negative C & S of urine

3. IVP or Renal Ultrasound (if renal insufficiency or contrast allergy) prior to consult.

1.Verify presence of three UA’s with at least six RCBs/HPF

2.Negative C & S of urine

3. IVP or Renal Ultrasound (if renal insufficiency or contrast allergy) prior to consult.

Structured ConsultStructured Consult

Tool to assist packaging the right way…

Tool to assist packaging the right way…

Referral ProcessConsult Flow

Patient Flow

Referral ProcessConsult Flow

Patient Flow

ColonoscopyOrdered

ColonoscopyOrdered

Chart reviewed by RNto find indications/

contraindications andlast exam

Chart reviewed by RNto find indications/

contraindications andlast exam

Chart Reviewedby Surgeon

Chart Reviewedby Surgeon

MeetsCriteriaMeets

Criteria

Call to Providerto Clarify

Call to Providerto Clarify

RN Calls patient toschedule and educate

Rn sends prep

RN Calls patient toschedule and educate

Rn sends prep

YESYESNONO

.15 to 2 hours X 25/wk.15 to 2 hours X 25/wk= 6 to 50 hours= 6 to 50 hours

5 to 205 to 20minmin X 25/wk X 25/wk= 2 to 4 hours per week= 2 to 4 hours per week

ProviderOrders

Colonoscopy

ProviderOrders

Colonoscopy

Provider fills outstructured consultProvider fills out

structured consult

Surgery schedules test,educates, sends prep

Surgery schedules test,educates, sends prep

5 min X 2/week5 min X 2/week

= 10 minutes= 10 minutes

Ideal Patient ExperienceIdeal Patient Experience

• Has clear understanding about and buy-in for referral from PCP

• PC Clerk reinforces expectations for referral negotiates ideal time and place for referral within 5 daysschedules specialty appointment at the time of check out from PCP

• Patient receives reminder material or call before appointment

• Has clear understanding about and buy-in for referral from PCP

• PC Clerk reinforces expectations for referral negotiates ideal time and place for referral within 5 daysschedules specialty appointment at the time of check out from PCP

• Patient receives reminder material or call before appointment

Ideal Patient Experience (cont)Ideal Patient Experience (cont)

• Specialty clerk warmly welcomes patientmentions who referred the patientReinforces reason for and expectations from referral

• Specialty provideris familiar with key historical factsis able to provide needed care in 1 or 2 visitsfacilitates smooth hand back to PCP

• Specialty clerk warmly welcomes patientmentions who referred the patientReinforces reason for and expectations from referral

• Specialty provideris familiar with key historical factsis able to provide needed care in 1 or 2 visitsfacilitates smooth hand back to PCP

3. Receiver: Is accessible for doing the right work right away

3. Receiver: Is accessible for doing the right work right away

Ways for Specialists to be AccessibleWays for Specialists to be Accessible

•Measure access parameters (wait, supply, demand, no-show, etc)

•Work down backlog

•Balance supply and demand

•Telephone

•“Question only” consults

•Measure access parameters (wait, supply, demand, no-show, etc)

•Work down backlog

•Balance supply and demand

•Telephone

•“Question only” consults

Wait Time for UrologyWait Time for Urology

00

1010

2020

3030

4040

5050

6060

1st Qtr1st Qtr 2nd Qtr2nd Qtr 3rd Qtr3rd Qtr 4th Qtr4th Qtr

Days to3ed nextDays to3ed next

Now Make and Agreement….Now Make and Agreement….

• “Primary Care will send the right patients appropriately worked up……in return, the specialists will be available to primary care anytime they are not in the OR and see patients quickly”

• “Primary Care will send the right patients appropriately worked up……in return, the specialists will be available to primary care anytime they are not in the OR and see patients quickly”

4. Referee – monitors for fair play

4. Referee – monitors for fair play

Audit: How we know it’s workingAudit: How we know it’s working

Develop measures (audit) for:Develop measures (audit) for:

•Wait time

•Audit of work (who is referring what?)

•Audit of important parts of process

•Wait time

•Audit of work (who is referring what?)

•Audit of important parts of process

Service Agreement Audit Quarter 4 '04 GIService Agreement Audit Quarter 4 '04 GI

GI Question #1: Receiver saw patient in agreed timeframeGI Question #1: Receiver saw patient in agreed timeframeGI Question #2: Sender referred the right casesGI Question #2: Sender referred the right casesGI Question #3: Sender provided the right informationGI Question #3: Sender provided the right information

Grp. 1

Grp. 1

Grp. 2

Grp. 2

Grp. 3

Grp. 3

Grp. 4

Grp. 4

Grp. 5

Grp. 5

Grp. 6

Grp. 6

Grp. 7

Grp. 7

Grp. 8

Grp. 8

System

Total

System

Total

120%120%

0%0%20%20%40%40%60%60%80%80%

100%100%

% C

om

pli

ance

% C

om

pli

ance

How to do it…How to do it…

Ideal Service Agreement Implementation Steps

Ideal Service Agreement Implementation Steps

1. Volume, reason, and source of existing referrals are measured and shared

2. Consultation scheduling process is flow-mapped

3. Face-to-face discussion between PC and Specialists occurs

Discuss current data

Discuss referral process

Small group tasked to work out agreement

1. Volume, reason, and source of existing referrals are measured and shared

2. Consultation scheduling process is flow-mapped

3. Face-to-face discussion between PC and Specialists occurs

Discuss current data

Discuss referral process

Small group tasked to work out agreement

Ideal Service Agreement Implementation Steps (Cont)Ideal Service Agreement

Implementation Steps (Cont)

4.One or 2 specific topics for future SA’s are chosen.

5.Simple SA is drafted

6.Consensus is reached among PC and SC providers for SA content, scheduling process, and audit criteria

7.Agreement is formally adopted by medical executive committee

4.One or 2 specific topics for future SA’s are chosen.

5.Simple SA is drafted

6.Consensus is reached among PC and SC providers for SA content, scheduling process, and audit criteria

7.Agreement is formally adopted by medical executive committee

8. SA implementation tools (structured consults, patient education, etc.) are implemented

9. Audit measures are tasked to be done periodically

10.Results of audit regularly discussed in face-to-face meeting of PC and Specialty providers

Ideas for improvement considered and adopted as needed

8. SA implementation tools (structured consults, patient education, etc.) are implemented

9. Audit measures are tasked to be done periodically

10.Results of audit regularly discussed in face-to-face meeting of PC and Specialty providers

Ideas for improvement considered and adopted as needed

Ideal Service Agreement Implementation Steps (Cont)Ideal Service Agreement

Implementation Steps (Cont)

Specialty ACA FacultySpecialty ACA Faculty

receive for preliminaryreceive for preliminary

reviewreview

Amb Care SLMAmb Care SLM

assign team toassign team to

review servicereview service

agreementsagreements

PC Team reviewsPC Team reviews

TAT 4 weeksTAT 4 weeks

ConsensusConsensus

requiredrequired

1. Accept w/o revision1. Accept w/o revision

2. Accept w/ minor revision2. Accept w/ minor revision

3. Not accepted3. Not accepted

Accepted?Accepted?

Signed by PC SLMSigned by PC SLM

& Specialty Chief& Specialty Chief

and distributedand distributed

Returned toReturned to

Specialty sectionSpecialty section

w/ recommendedw/ recommended

changes &changes &

rationalerationale

Annual review bySpecialty and PC

for concurrence and/oramendment

Annual review bySpecialty and PC

for concurrence and/oramendment

Make minorMake minor

revisions ifrevisions if

needed, getneeded, get

concurrencesconcurrences

YesYes

NoNo

Approval ProcessApproval Process

• Agreement by subspecialists and Primary Care

• Signatures by Specialty Care Chief and Primary Care Chief

• Approval by Executive Committee of the Medical Staff

• Agreement by subspecialists and Primary Care

• Signatures by Specialty Care Chief and Primary Care Chief

• Approval by Executive Committee of the Medical Staff

Individual Focused EducationIndividual Focused Education

•Find the most frequent referrers to the service

•One-on-one, or facilitated discussion about reasons for referral

•Measure before and after discussion

•Find the most frequent referrers to the service

•One-on-one, or facilitated discussion about reasons for referral

•Measure before and after discussion

Service AgreementService Agreement

Effect of Strategies on Demand Reduction in Specialty Care

Effect of Strategies on Demand Reduction in Specialty Care

Focused Education

0022446688

101012121414161618182020

Each Bar Represents 1 MDEach Bar Represents 1 MD

Mean 8.6Mean 8.6

SA Example SA Example

Surgery ExampleSurgery Example

*FY 03 data as of 4/30/03*FY 03 data as of 4/30/03

42744274

36743674 36063606

17831783

78678610921092 11381138 13151315

00500500

1000100015001500200020002500250030003000350035004000400045004500

FY 00 FY 01 FY 02 FY 03

nn

Completed Office Visits

OR Cases

Ratio: 3.9Ratio: 3.9 Ratio: 3.2Ratio: 3.2 Ratio: 2.7Ratio: 2.7

Ratio: 2.3Ratio: 2.3

Major Cases, FY 94-02Major Cases, FY 94-02

00

200200

400400

600600

800800

10001000

12001200

Maj

or C

ases

Maj

or C

ases

19941994 19951995 19961996 19971997 19981998 19991999 20002000 20012001 20022002 FYFY

Bivariate Line Chart, Major Cases vs Fiscal YearBivariate Line Chart, Major Cases vs Fiscal YearGrouping Variable: ServiceGrouping Variable: ServiceData Sources: Surgical Service Summary Report; Special Procedures LogbookData Sources: Surgical Service Summary Report; Special Procedures Logbook

764846 835

927869

916 953 958

1100

UrologyOrthopedicsOphthalmologyNeurosurgeryENT5C Services

AGREEMENT BETWEEN PRIMARY CARE AND GASTROENTEROLOGY

• To facilitate patient care by reducing waiting time to obtain a screening colonoscopy.

• To facilitate patient care by increasing the percentage of patients who are appropriately screened for colorectal carcinoma.

1. To facilitate patient care by decreasing the interval between a positive test for blood in the feces and initiation of therapy for colorectal carcinoma.

AGREEMENT BETWEEN PRIMARY CARE AND GASTROENTEROLOGY

• To facilitate patient care by reducing waiting time to obtain a screening colonoscopy.

• To facilitate patient care by increasing the percentage of patients who are appropriately screened for colorectal carcinoma.

1. To facilitate patient care by decreasing the interval between a positive test for blood in the feces and initiation of therapy for colorectal carcinoma.

Oklahoma Example AgreementOklahoma Example Agreement

1. Issue hemoccult cards to each non-screened patient over 50 who is not terminal and agrees to screening.

2. Evaluate those patients who have positive result. This colonoscopy, to fully inform patient about risks and benefits of a colonoscopy, and to set up appointment including ordering preparatory medications.

3. Adjust anticoagulant therapy as needed for those patients on warfarin.

4. Enter pre-colonoscopy note in the record.5. Call patients prior to scheduled exam to reduce no-

show rates.

1. Issue hemoccult cards to each non-screened patient over 50 who is not terminal and agrees to screening.

2. Evaluate those patients who have positive result. This colonoscopy, to fully inform patient about risks and benefits of a colonoscopy, and to set up appointment including ordering preparatory medications.

3. Adjust anticoagulant therapy as needed for those patients on warfarin.

4. Enter pre-colonoscopy note in the record.5. Call patients prior to scheduled exam to reduce no-

show rates.

Primary Care WillPrimary Care Will

1. Maintain enough open capacity to accommodate scheduling within 2- 4 weeks.

2. Enter reports including CPT codes into the record.

3. Recommend appropriate follow-up for patients after colonoscopy.

4. Open appointment capability so that Primary Care may schedule directly following guidelines.

5. Educate clinicians regarding appropriate screening intervals and techniques.

1. Maintain enough open capacity to accommodate scheduling within 2- 4 weeks.

2. Enter reports including CPT codes into the record.

3. Recommend appropriate follow-up for patients after colonoscopy.

4. Open appointment capability so that Primary Care may schedule directly following guidelines.

5. Educate clinicians regarding appropriate screening intervals and techniques.

Gastroenterology WillGastroenterology Will

Clarify the Pathways:Back Pain Example

Clarify the Pathways:Back Pain Example

•Services that treat back pain

Physical Therapy

Neurology

Neurosurgery

Physiatry

Orthopedics

•Services that treat back pain

Physical Therapy

Neurology

Neurosurgery

Physiatry

Orthopedics

SummarySummary

•Define and discuss the work: Who is sending it and what it is

•Sender sends the right work the right way

•Receiver does today’s work today – and is accessible to the sender

•Referee audits agreement

•Define and discuss the work: Who is sending it and what it is

•Sender sends the right work the right way

•Receiver does today’s work today – and is accessible to the sender

•Referee audits agreement

National Database “Mining” (Audit)

National Database “Mining” (Audit)

Bill BarrBill Barr

Eye Care carries a large proportion of Established Patients in its Case Load.

Eye Care carries a large proportion of Established Patients in its Case Load.